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Purpose in life is a well-established contributor to positive well-being. However, for a more comprehensive understanding of purpose in life, further exploration is needed about the processes implicated in purpose from a cognitive and affective perspective. This scoping review aims to identify the cognitive and/or affective mechanisms (CAMs) correlating with purpose in life and to examine these relationships based on relevant existing literature. Using search terms related to CAMs and purpose in life, we conducted a comprehensive search across five databases (Web of Science, Medline, Pubmed, Scopus, and psycinfo) to identify those examining the relationship between these constructs. Ninety-nine manuscripts were selected for inclusion. Within these studies, 33 CAMs showed predominantly positive and significant associations with purpose in life. Our findings highlighted the cams empirically and theoretically implicated in purpose development, maintenance, and its association to positive wellbeing. We identified several gaps in current research including issues related to suboptimal measurement of purpose in life, and a lack of longitudinal and intervention studies. Overall, this study represents a foundational step in advancing an understanding CAMs implicated in purpose in life. This scoping review usefully informs the development and validation of future purpose in life measures, and the design of interventions aimed at enhancing purpose in life and wellbeing. [ABSTRACT FROM AUTHOR]

Objectives: Informal carers are an integral part of any health care system. However, provision of informal care is associated with caregiver burden and decreased wellbeing. Mindfulness programs can reduce caregiving burden and improve wellbeing among informal carers, but they face challenges when participating in face-to-face programs. Studies have explored the effects of online delivery of mindfulness programs for informal carers. However, the enablers and barriers for participation are not well understood. This review aimed to synthesise the evidence and provide a comprehensive understanding of the enablers and barriers to participation in online mindfulness programs among this population. Methods: A mixed-methods systematic review was conducted following the Joanna Briggs Institute mixed-methods systematic review approach and using eight databases. All empirical studies published in English and involving informal carers aged over 18 years were included. Critical appraisal was conducted using the Mixed Methods Appraisal Tool. Thematic analysis was conducted to integrate the data. Results: Nine studies were included: three quantitative, two qualitative, and four mixed methods. Three subthemes for enablers and barriers were developed. Three subthemes for enablers included self-motivation, positive experience of mindfulness, and program structure and delivery. Three subthemes for barriers included lack of self-motivation, external factors preventing participation, and program structure and delivery. The enablers and barriers were interrelated within and across the identified themes. Conclusions: A comprehensive synthesis of current evidence was provided for consideration when developing online mindfulness-based interventions for informal carers. Further investigation is recommended, particularly in relation to the enablers and barriers to engagement by informal carers. Preregistration: The review protocol was registered with PROSPERO (CRD42023409311). [ABSTRACT FROM AUTHOR]

Anxiety has been conceptualized in terms of increased avoidance motivation and higher expectancies of undesirable outcomes. However, anxiety research has hitherto not examined an important qualitative aspect of motivation: the degree to which reasons for goal pursuit are experienced as controlling and originating outside the core self. We asked 70 adolescents (34 boys, 36 girls; aged 16-18 years) to list their important approach and avoidance goals, and rate the extent to which they pursued each goal for intrinsic, identified, introjected and external reasons. Participants also rated goal importance, expectancies for goal outcomes, and completed an anxious symptom measure. Broadly in line with predictions, anxiety was significantly associated with introjected reasons for pursuing approach goals and external reasons for pursuing avoidance goals but not with autonomous reasons for goal pursuit. As predicted, anxiety was significantly associated with heightened expectancies of undesirable avoidance goal outcomes, but not with expectancies for desirable approach goal outcomes. Results suggest that the salient role of avoidance-based motivation in anxiety extends to introjected reasons underlying approach goal pursuit. Our findings point to the theoretical and clinical importance of addressing controlled reasons for goal pursuit in adolescent anxiety.

Goal orientation (approach versus avoidance) and difficulties in emotion regulation have been independently associated with depression and anxiety. However, there is a lack of research that has simultaneously examined approach and avoidance goal motives and emotion regulation difficulties in depression and anxiety. The present study aims to draw together these separate lines of investigation to better understand the nature of depression and anxiety from a motivational and emotional regulation perspective. Specifically, it aims to investigate whether increased emotion regulation difficulties indirectly mediate, in part, distinct relationships between approach and avoidance goal motives and depressive and anxious symptoms. An online study comprised 210 participants recruited via Facebook and MTurk. Participants completed self-reported measures to rate their approach and avoidance goal motives, emotion regulation and depressive and anxious symptoms. Counter to prediction, no significant relationship was demonstrated between impaired approach motives and increased depressive symptoms. However, as predicted, avoidance goal motives were associated with depressive and anxious symptoms. Further, increased emotion regulation difficulties indirectly mediated relationships between avoidance goal motives and both depressive and anxious symptoms. Our findings indicate that emotion regulation difficulties play a significant role in explaining the relationship between avoidance (but not approach) oriented motives in goal pursuit and emotional symptom. What is already known about this topic: Much research has examined approach and avoidance 'goals' in relation to anxiety and depression. There is strong empirical evidence to indicate that avoidance goal pursuit (focused on threatening outcomes) is associated with anxiety whereas impaired approach goal pursuit (focused on reward outcomes) is associated with depression. However, research has rarely studied underlying 'motives' that drive goal pursuit. Motives represent a more primary form of motivation than that expressed at the surface goal level. For instance, it is possible that an underlying avoidance motive energises and drives approach goal pursuit. We also know that emotion regulation is implicated in emotional symptoms such as anxiety and depression. Despite well-developed two-system theories of motivation and emotion regulation, research has rarely investigated the relationship between distinct approach and avoidance motives and emotion regulation in relation to depression and anxiety, which the present study addressed. What this topic adds: The research findings inform an understanding of the nature of depression and anxiety from both a motivation and emotion regulation perspective. Notably, avoidance motives gave rise to emotional regulation difficulties, which in turn indirectly explained the relationship between avoidance motives (but not approach motives) and depression and anxiety. These findings further inform theoretical developments when considering motivation and emotion regulation simultaneously. The findings inform the ongoing development of more effective interventions in treating anxious and depressive symptoms, from a motivation-emotion regulation perspective. [ABSTRACT FROM AUTHOR]

Existing research that attempts to understand aggressive behavior often focuses on adults and/or individual traits. The present study used a Grounded Theory approach to develop a theoretical framework of how younger adolescents constructed an understanding of their own aggressive behavior within the social context of their lives. The participants were 11 adolescents (aged 12-16) who had previously been involved in incidents of aggression at a school for children with emotional and behavioral difficulties. The identified theoretical framework outlined that aggressive behavior was fundamental to an identity of toughness that participants sought to portray to others. This identity emerged in a hostile peer environment to prevent victimization and establish friendships. The findings are discussed in relation to their clinical implications, limitations, and possibilities for further research. (Contains 2 tables, 1 figure, and 1 note.)

Background: This paper examines the experiences of people with intellectual disabilities, in secure care, with a diagnosis of schizophrenia. The paper specifically looks at the perceptions of the participants in relation to their diagnosis and experience of psychosis. Method: Eleven adults with intellectual disabilities in a medium secure unit were interviewed about their experiences and understanding of their diagnosis of schizophrenia and symptoms of psychosis. The transcripts were analysed using Interpretative Phenomenological Analysis (IPA). Results: Three Superordinate themes were evident within the data as well as several subthemes; (i) reality of symptoms (voices as controlling/malevolent, symptoms as a real lived experience); (ii) making sense/a search for meaning (normalization, religious/spiritual explanation, psychotic symptoms as a sign of illness) and (iii) Perceptions of being labelled. Conclusion: The results highlighted that people with intellectual disabilities hold multiple frameworks in understanding both their diagnosis of schizophrenia and the associated symptoms of psychosis. The findings provide further insight into the experiences of people with intellectual disabilities, specifically those detained within a medium secure unit. The clinical implications are discussed in terms of developing services and therapeutic approaches.

Relatively little research has studied emotional disturbance from a motivational perspective. The current study aimed to investigate personal goal systems at different levels of analysis, namely, personal goals, associated causal explanations and goal expectancies, as a function of dysphoria. Dysphoric (n=28) and non-dysphoric (n=28) adolescents (16-18-yr-olds) selected from a larger school sample completed tasks that measured number of approach goals and avoidance goals, causal explanations for goals, and perceived likelihood and control estimates for idiographic goals. As predicted dysphoric adolescents, relative to controls, generated a combination of more avoidance goals and fewer approach goals, and thought of more reasons that explain why goals would not be achieved and fewer reasons that explain why goals would be achieved (irrespective of goal type), and considered avoidance goal outcomes as more likely to occur and approach goal outcomes as less likely to occur. In addition, dysphoric adolescents anticipated less personal control in implementing their goals than controls. Overall, the data identified distinct personal goal systems that function differently in dysphoric and non-dysphoric adolescents.

Health-related behaviours contribute to the global burden of cardiovascular disease (CVD). Cardiovascular imaging can be used to screen asymptomatic individuals for increased risk of CVD to enable earlier interventions to promote health-related behaviours to prevent or reduce CVD risk. Some theories of behaviour and behaviour change assume that engagement in a given behaviour is a function of individual threat appraisals, beliefs regarding the performance of behaviour, self-efficacy for performing the desired behaviour and/or dispositions to act (e.g. behavioural intentions). To date, little is known about the impact of cardiovascular imaging interventions on these constructs. This article summarises evidence related to perceived threat, efficacy beliefs, and behavioural intentions after CVD screening. We identified 10 studies (2 RCTs and 8 non-randomised studies, n = 2498) through a combination of screening citations from published systematic reviews and meta-analyses and searching electronic databases. Of these, 7 measured behavioural intentions and perceived susceptibility and 3 measured efficacy beliefs. Findings showed largely encouraging effects of screening interventions on bolstering self-efficacy beliefs and strengthening behavioural intentions. Imaging results that suggest the presence of coronary or carotid artery disease also increased perceived susceptibility to CVD. However, the review also identified some gaps in the literature, such as a lack of guiding theoretical frameworks and assessments of critical determinants of health-related behaviours. By carefully considering the key issues highlighted in this review, we can make significant strides towards reducing CVD risks and improving population health. [ABSTRACT FROM AUTHOR]

It is suggested that goals are hierarchically organised, with goals at the highest level representing fundamental values and motivations. These abstract goals are said to have a series of sub-goals which represent a means of reaching higher-level goals. While a number of studies have explored goals in the context of psychosis, little is known about idiographic goal generation processes in those experiencing psychosis. Using a Behaviour Sequence Analysis approach, the aim of the current study was to assess the feasibility of the goal task for use with individuals experiencing psychosis. A total of 73 adults receiving care from UK rehabilitation services completed a goal task designed to elicit higher-level goals. Results indicated that the goal task may be a feasible tool to support those experiencing psychosis to generate lower- and higher-level goals. The goal task utilised in the current study may therefore be a valuable goal generation tool for use by clinicians. [ABSTRACT FROM AUTHOR]

Aims Psychological distress and changes in health-related quality of life (HRQoL) may occur after screening for disease. Reporting outcomes related to potential benefits and harms of screening is a key recommendation in the guidelines for reporting high-quality trials or interventions. However, no reviews have directly investigated outcomes related to psychological distress and/or changes in HRQoL following imaging assessment of cardiovascular risk and communication of cardiovascular findings to asymptomatic adults. A scoping review was conducted to map research on psychological distress and/or HRQoL following screening. Methods and results Six electronic databases (MEDLINE, PsychINFO, Social Work Abstracts, Psychology and Behavioural Sciences Collection, CINAHL, and EMBASE) were searched for articles that assessed psychological distress and/or HRQoL following screening. Two investigators independently screened titles and abstracts for all records retrieved using predefined criteria. Studies were conducted among active smokers, military personnel, athletes, post-menopausal women, and high-risk individuals. Seven constructs related to psychological distress and HRQoL appeared across 11 articles (randomized controlled trials, n = 4 and non-randomized studies, n = 7). Worry, depression, perceived stress, anxiety, and quality of life were most prominent. Multiple-item measures of psychological distress (e.g. Taylor Anxiety Score and Beck Depression Inventory) were used in 5/9 (56%) studies. Key findings on psychological distress and/or changes in HRQoL following screening were mixed. Conclusions Findings support the need for multiple-item measures with better psychometric properties to examine the psychological responses to screening results in future studies. Strategies to support individuals during and following vascular screening to maximise potential benefits of screening and minimize harms are discussed. [ABSTRACT FROM AUTHOR]

The goal of this study was to develop and validate a measure of self-rated positive and negative beliefs about one's non-suicidal self-injury (NSSI), the Experiences of Self-Injury Questionnaire (ESIQ). Psychometric properties and validation against NSSI severity and shame were tested in two U.S. and two U.K. samples of individuals who endorsed a history of NSSI. Exploratory and confirmatory factor analyses indicated five factors. Subscales were labeled Positive Beliefs, Personal Dislike, Interpersonal Concern, Emotional Suppression, and Emotional Expression. The Positive Beliefs Subscale covers beliefs that NSSI is valuable. Scores on this subscale were associated with endorsement of NSSI frequency, NSSI urges, and perceived likelihood of future NSSI. Other subscales showed validity in that they all showed unique effects on outcome indices of NSSI severity or shame. The ESIQ shows promise as a brief reliable measure of beliefs about and experiences of NSSI. [ABSTRACT FROM AUTHOR]

Objective: Emotional distress, including depression and anxiety, is commonly reported amongst individuals experiencing psychosis. The beliefs individuals hold about the meaning of their psychosis may explain the distress they experience. The current meta‐analysis aimed to review the association between beliefs about psychosis experiences and emotional distress. Method: Three electronic databases (PsycINFO, MEDLINE, and CINAHL) were searched using keywords and controlled vocabulary (e.g., Medical Subject Headings) from date of inception to August 2019. A total of 19 eligible papers were identified. Results: Our random‐effects meta‐analysis revealed that depression and anxiety held moderate association with psychosis beliefs, with perceptions concerning a lack of control over experiences having the strongest association with distress. Longitudinal studies suggest that negative beliefs at baseline are associated with depressive symptoms at follow‐up. Conclusions: The results suggest that the endorsement of negative beliefs about psychosis is associated with current level of depression and anxiety. The results are consistent with theories of emotional distress in psychosis. However, the small number of longitudinal papers limits what can be concluded about the direction or other temporal characteristics of these relationships. Therapies that target unhelpful beliefs about psychosis may beneficial. Practitioner points: Negative beliefs about experiences of psychosis are associated with greater emotional distress such as depression and anxiety.Beliefs about a lack of control over experiences had the strongest association with distress.Interventions that aim to modify or prevent the formation of unhelpful beliefs about psychosis may be beneficial for this population. [ABSTRACT FROM AUTHOR]

Background: Brief psychological therapies may be helpful for people who have recently self‐harmed. The current paper reports on a service evaluation of a novel brief therapy service based within an Emergency Department, Hospital Outpatient Psychotherapy Engagement (HOPE) Service. This service combines elements of psychodynamic interpersonal and cognitive analytic therapy to help people who present with self‐harm‐related difficulties. The primary aim of this service evaluation was to ascertain the feasibility of HOPE in terms of attendance rates. The study also examined variables associated with engagement, and change over time in psychological distress for those attending the service. Method: The HOPE service was evaluated over a ten‐month period. Consenting patients completed measures of psychological distress and working alliance across four therapy sessions and one follow‐up session. Measures of emotion regulation style and self‐harm function were also completed at the point of referral. Results: Eight‐nine patients were referred to the service (83 eligible referrals). Fifty‐three (64%) attended at least one therapy session. Baseline variables did not distinguish people who attended and people who did not. Psychological distress decreased significantly across the sessions. Most people reported a good working alliance with their therapist. Conclusions: The results of this service evaluation support the feasibility of the HOPE service, demonstrating good engagement rates given the complexity of the population and context. Whilst there was evidence of reductions in distress, randomized controlled trials are needed to determine if HOPE has clinical efficacy. Practitioner points: Rates of engagement with HOPE suggest the service is feasible in an Emergency Department contextWorking alliance scores were positive for the majority of patientsThe HOPE service shows promise as a brief intervention for people who self‐harm but requires further evaluationRandomized controlled trials are needed to determine the clinical efficacy of the HOPE service [ABSTRACT FROM AUTHOR]

Objectives: Emotional states may play an important role in the development and maintenance of anorexia (AN) and bulimia nervosa (BN). This systematic review aimed to examine the evidence regarding the relationship that shame and guilt have with two eating disorders, AN and BN. Methods: Four major databases (Pubmed, PsychINFO, Web of Science, Medline) were searched (up until April 2018) for studies measuring guilt or shame in clinically diagnosed AN and BN groups. Included papers were evaluated for risk of bias. Results: Twenty‐four papers met the inclusion criteria. Several methodological issues were noted within the reviewed studies, including a lack of longitudinal data and unaccounted confounding variables. Nonetheless, shame was typically more common in those with AN and BN than controls, was positively related to the severity of symptoms, and associated with the onset of eating disorder‐related difficulties (e.g., binging or purging). Effect sizes were typically moderate to large. The role of guilt was less clear, with few studies and mixed results. Discussion: There is preliminary evidence that shame is implicated in the aetiology of AN and BN presentations, whilst there is currently insufficient evidence of such a role for guilt. It remains unclear whether shame is a risk factor for the development of AN and BN or a consequence of these difficulties. Practitioner Points: Elevated shame appears to be a feature of anorexia (AN) and bulimia nervosa (BN).Shame appears to fluctuate with the occurrence of eating disordered behaviours like binging, purging or restricted eating.Guilt is less consistently linked to AN and BN presentations.Interventions directed at shame may be helpful for these populations.A lack of longitudinal data means the temporal features of these relationships are still unclear. [ABSTRACT FROM AUTHOR]

This study explores the association between lesbian, gay or bisexual (LGB) status and self-harm in UK higher education students. There is currently limited data on this association, and the role psychological variables have in potentially explaining this link, in UK students. We examine whether LGB status is associated with self-harm (both non-suicidal self-injury [NSSI] and suicide attempts [SA]), and whether 4 psychological variables (depression, anxiety, belongingness, self-esteem) mediate this association. A cross-sectional survey was used. UK university students (n = 707) completed an online survey including measures of self-harm, affective symptoms, belongingness, and self-esteem. Latent Variable Modelling (LVM) was used to test our hypotheses. LGB status remained associated with an elevated risk of NSSI and SA even after accounting for mediating factors. Self-esteem and (in the case of SA but not NSSI) thwarted belongingness, did, however, explain some of this association and were correlated with self-harm risk. The findings suggest that psychological factors may account for the association between LGB status and self-harm and, as such, prevention and intervention efforts directed at these psychological mediators may help to reduce self-harm risk in this population. [ABSTRACT FROM AUTHOR]

Objective: To examine the accuracy of Health Visitors (HVs) evaluations of the quality of parent-infant interactions. Background: HVs have been identified as key professionals in the early identification of difficulties in parent-infant interactions. Method: A sample of 56 HVs, 4 Family Health Nurses (FHNs) and 14 Community Nursery Nurses (CNNs) recruited from two National Health Service (NHS) Trusts, viewed video footage of six early parent-infant interactions which had been categorised as 'sensitive', 'mixed', and 'problematic' using the CARE-Index. Participants evaluated the quality of the parent-infant interactions shown in these videos using the Parent-Infant Interaction Rating Questionnaire (PIIRQ). Results: On average, participants correctly rated the problematic videos as lowest in quality, the mixed as higher in quality than the problematic videos, and the sensitive videos as highest in quality. Interestingly, within the problematic category participants rated the 'unresponsive' pattern of interaction as significantly lower in quality than the 'controlling' interaction. Conclusions: Findings suggest participants were relatively accurate in their evaluations of parent-infant interactions. However, they indicate that participants were more likely to be concerned about unresponsive, as opposed to controlling, interactive behaviours. Recommendations for further research include exploration of potential differences in how health-visiting professionals evaluate particular patterns of parent-infant interactions. [ABSTRACT FROM AUTHOR]

Individuals with chronic pain commonly report significant functional impairment and reduced quality of life. Despite this, little is known about psychological processes and mechanisms underpinning enhancements in well-being within this population. The study aimed to investigate whether (1) increased levels of pain intensity and interference were associated with lower levels of mental well-being, (2) increased positive goal engagement was associated with higher levels of mental well-being and (3) whether the relationships between pain characteristics and mental well-being were mediated by increased positive goal engagement. A total of 586 individuals with chronic pain participated in the cross-sectional, online study. Participants completed self-report measures to assess pain intensity and interference, mental well-being and goal motivation variables. Results showed that pain interference and positive goal engagement were associated with mental well-being. Moreover, the relationship between pain interference and mental well-being was partially mediated by positive goal engagement. The results provide tentative evidence for the protective role of positive goal engagement in enabling individuals with chronic pain to maintain a sense of mental well-being. The study develops the biopsychosocial model of chronic pain by examining the roles and relationships of relevant yet previously unexplored psychological constructs. The promotion of mental well-being through the enhancement of positive goal engagement is discussed, offering a platform for further research and clinical interventions. [ABSTRACT FROM AUTHOR]

Objective: Lower socioeconomic status is robustly associated with obesity; however, the underpinning psychological mechanisms remain unclear. The current study sought to determine whether the relationship between lower socioeconomic status and obesity is explained by psychological distress and subsequent emotional eating as a coping strategy. It also examined whether psychological resilience plays a protective role in this pathway.Methods: Participants (N = 150) from a range of socioeconomic backgrounds completed questionnaire measures of psychological distress, emotional eating, and resilience. They reported their income and education level as an indicator of socioeconomic status and their height and weight in order to calculate BMI.Results: There was a significant indirect effect of socioeconomic status on BMI via psychological distress and emotional eating; specifically, lower socioeconomic status was associated with higher distress, higher distress was associated with higher emotional eating, and higher emotional eating was associated with higher BMI (b [SE] = -0.02 [0.01]; 95% CI: -0.04 to -0.01). However, resilience was not a significant moderator of this association.Conclusions: Psychological distress and subsequent emotional eating represent a serial pathway that links lower socioeconomic status with obesity. Targeting these maladaptive coping behaviors may be one strategy to reduce obesity in low-income populations. [ABSTRACT FROM AUTHOR]

Alcohol dependence is characterized by conflict between approach and avoidance motivational orientations for alcohol that operate in automatic and controlled processes. This article describes the first study to investigate the predictive validity of these motivational orientations for relapse to drinking after discharge from alcohol detoxification treatment in alcohol-dependent patients. One hundred twenty alcohol-dependent patients who were nearing the end of inpatient detoxification treatment completed measures of self-reported (Approach and Avoidance of Alcohol Questionnaire; AAAQ) and automatic (modified Stimulus-Response Compatibility task) approach and avoidance motivational orientations for alcohol. Their drinking behavior was assessed via telephone follow-ups at 2, 4, and 6 months after discharge from treatment. Results indicated that, after controlling for the severity of alcohol dependence, strong automatic avoidance tendencies for alcohol cues were predictive of higher percentage of heavy drinking days (PHDD) at 4-month (β = 0.22, 95% CI [0.07, 0.43]) and 6-month (β = 0.22, 95% CI [0.01, 0.42]) follow-ups. We failed to replicate previous demonstrations of the predictive validity of approach subscales of the AAAQ for relapse to drinking, and there were no significant predictors of PHDD at 2-month follow-up. In conclusion, strong automatic avoidance tendencies predicted relapse to drinking after inpatient detoxification treatment, but automatic approach tendencies and self-reported approach and avoidance tendencies were not predictive in this study. Our results extend previous findings and help to resolve ambiguities with earlier studies that investigated the roles of automatic and controlled cognitive processes in recovery from alcohol dependence. (PsycINFO Database Record [ABSTRACT FROM AUTHOR]

Despite the development of prominent theoretical models of goal motivation and its importance in daily life, research has rarely examined goal dysregulation processes in clinical depression. Here we aimed to investigate problematic aspects of goal regulation in clinically depressed adults, relative to controls. Depressed participants (n = 42) were recruited from two Improving Access to Psychological Therapy clinics in north-west England. Control participants (n = 51) were recruited from the same region. Participants generated personal approach goals (e.g., improve my marathon time) and avoidance goals (e.g., avoid getting upset over little things) and completed self-report measures of goal attainment likelihood and depressive symptoms. Participants also completed a measure of ease of disengagement from unattainable goals and re-engagement with new goals. Compared to controls, depressed participants reported fewer approach goals (but not more avoidance goals), rated their approach goal (rewarding) outcomes as less likely to happen and avoidance goal (threatening) outcomes as more likely to happen. Depressed participants also reported greater ease of disengagement from unattainable goals and more difficulty re-engaging with new goals than controls. Our findings extend current knowledge of the psychopathology of depression from a goal regulation perspective, suggesting that pessimism around goal pursuit accompanies fewer approach goal pursuits and a general tendency to disengage when difficulties are encountered. [ABSTRACT FROM AUTHOR]

Dear Sir, As the world continues to navigate the global pandemic (COVID-19) and went into lockdowns of varying degrees, traditional health care delivery was forced to transform into online or telehealth forums. The original recruitment method possibly failed because patrons felt overwhelmed, exhausted or preoccupied at the beginning and end of their psychological therapy session, as they focus on payment and scheduling future appointments.[3] Direct recruitment with specific timeframes may have been a deterrent. [Extracted from the article]